Unsafe abortion

An unsafe abortion is the termination of a pregnancy by people lacking the necessary skills, or in an environment lacking minimal medical standards, or both. An unsafe abortion is a life-threatening procedure. It includes self-induced abortions, abortions in unhygienic conditions, and abortions performed by a medical practitioner who does not provide appropriate post-abortion attention. About 25 million unsafe abortions occur a year, of which most occur in the developing world.

Soviet poster circa 1925. Title translation: "Abortions induced by grandma or self-taught midwives not only maim the woman, they also often lead to death"

QuotesEdit

  • Unsafe abortion and associated morbidity and mortality in women are completely avoidable. This paper reports on an analysis of the association between legal grounds for abortion in national laws and unsafe abortion, drawing on an unpublished study and using estimates of the incidence of and mortality from unsafe abortion using information from the sources used to estimate the incidence of unsafe abortion and associated mortality in 2000. Although legal grounds alone may not reflect the way in which the law is applied, nor the quality of services offered, a clear pattern was found in more than 160 countries indicating that where legislation allows abortion on broad indications, there is a lower incidence of unsafe abortion and much lower mortality from unsafe abortions, as compared to legislation that greatly restricts abortion. The data also show that most abortions become safe mainly or only where women's reasons for abortion, and the legal grounds for abortion coincide. This is a compelling public health argument for making abortion legal on the broadest possible grounds. A wide range of actions have formed part of national campaigns for safe, legal abortion over the past century, covering law reform, provision of safe services, ensuring quality of care, training for providers and information and support for women. Safe abortion is an essential health service for women, as essential for sexual and reproductive health as safe contraception, and safe pregnancy and delivery care. In spite of sometimes powerful opposition and terrible setbacks, the public health imperative is gaining ground in many parts of the globe.
  • It is the number of maternal injuries and deaths, not abortions, that is most affected by restrictive legal codes. Abortions performed outside the law have a higher rate of complications and deaths, the majority of which are entirely preventable. Worldwide, more than one third of the estimated 50 million annual abortions are illegal abortions, occurring mainly in the developing world. Researchers estimate that 70,000 to 200,000 women a year around the world die from illegal and unsafe abortions. Doing away with such purposeless human suffering has been one of the main motives behind the movement to liberalize abortion laws the world over.
    At present almost two thirds of the world’s women live in countries where abortion may be legally obtained for a broad range of social, economic or personal reasons. When abortion is made legal, available and safe, women’s reproductive health improves. Abortion-related mortality is reduced by at least 25% and related illness by far more. Where abortions are safe and affordable, by far the largest percentage of women terminate their pregnancies within the first trimester.
    When women can avoid births which are unwanted, mistimed, or too numerous, their children are more likely to survive and be healthy. The incidence of infanticide and child abandonment typically go down when abortion is legalized.
    Even in countries where the abortion law seems “liberal”, it cannot be assumed that every woman has an equal chance of getting an early, safe abortion if she needs one. Lack of medical facilities or personnel, women’s low status in society, cultural taboos, restrictive regulations and financial roadblocks can effectively curtail access to legal abortion and contraception, especially for disadvantaged and young, unmarried women. Changes in laws, while necessary, are not themselves sufficient for widespread access to family planning and safe abortion services.
  • The latest World Health Organization data estimate that the total number of unsafe abortions globally has increased to 21.6 million in 2008. There is increasing recognition by the international community of the importance of the contribution of unsafe abortion to maternal mortality. However, the barriers to delivery of safe abortion services are many. In 68 countries, home to 26% of the world's population, abortion is prohibited altogether or only permitted to save a woman's life. Even in countries with more liberal abortion legal frameworks, additional social, economic, and health systems barriers and the stigma surrounding abortion prevent adequate access to safe abortion services and postabortion care. While much has been achieved to reduce the barriers to comprehensive abortion care, much remains to be done. Only through the concerted action of public, private, and civil society partners can we ensure that women have access to services that are safe, affordable, confidential, and stigma free.
  • Unsafe abortion accounts for a significant proportion of maternal deaths, yet it is often forgotten in discussions around reducing maternal mortality. Prevention of unsafe abortion starts with prevention of unwanted pregnancies, most effectively through contraception. When unwanted pregnancies occur, provision of safe, legal abortion services can further prevent unsafe abortions. If complications arise from unsafe abortion, emergency treatment must be available.
  • Unsafe abortion is one of the most neglected public health challenges in the Middle East and North Africa (MENA) region, where an estimated one in four pregnancies are unintended—wanting to have a child later or wanting no more children. Many women with unintended pregnancies resort to clandestine abortions that are not safe. According to the World Health Organization (WHO), around 1.5 million abortions in MENA in 2003 were performed in unsanitary settings, by unskilled providers, or both. Complications from those abortions accounted for 11 percent of maternal deaths in the region.
    • Dabash, Rasha; Roudi-Fahimi, Farzaneh (2008). "Abortion in the Middle East and North Africa" (PDF). Population Research Bureau. Archived (PDF) from the original on 6 October 2011. p.1
  • Unsafe abortion is preventable, but it remains a major global health issue causing unnecessary threats to women’s health and burdens on the health system. Globally, an estimated 25 million abortions (45% of the total 55.7 million) that occur every year are unsafe, with most (97%; 24 million) occurring in low‐resource settings where countries that highly restrict abortion are concentrated. Unsafe abortion results in an estimated 47,000 maternal deaths a year, and an additional 6.9 million women are estimated to suffer morbidities from complications due to unsafe abortion. The World Health Organization (WHO) defines unsafe abortion as a procedure for terminating an unintended pregnancy carried out by either a person lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both. Since 2000, with the advent and ubiquitous access to medical abortion drugs, safe abortion has increased, and abortion‐related morbidity and mortality have improved.
  • It is estimated that in 2000 27 million legal and 19 million illegal abortions were performed worldwide. Up to 95% of illegal abortions (unsafe abortions) were performed in developing countries and 99% of deaths from these abortions also occurred in those countries. Access to safe abortion is limited in many developing countries because of legal restrictions, administrative barriers to access legal abortion services, financial barriers and lack of adequately trained providers, In Latin America, rural women with limited financial resources disproportionately suffer from complications of illegal abortion.
    • Grossman D (3 September 2004). "Medical methods for first trimester abortion: RHL commentary". Reproductive Health Library. Geneva: World Health Organization. Archived from the original on 28 October 2011. Retrieved 22 November 2011.
  • Unsafe abortion has been identified as one of the most easily preventable causes of maternal ill-health and death, yet it continues to threaten the health and lives of women globally. This has led some commentators to declare that ‘ending the silent pandemic of unsafe abortion is an urgent public-health and human-rights imperative’ (Grimes et al 2006). In response to the issues and challenges raised by this situation, the WHO (2004, 2007b) has deemed ‘preventing unsafe abortion’ a strategic priority underpinned by the following two goals:
    in circumstances where abortion is not against the law, to ensure that abortion is safe and accessible
    in all cases, women should have access to quality services for the management of complications arising from abortion.
  • Nearly 8% of maternal deaths worldwide are abortion-related and 99.5% of these occurring in developing regions. There is strong evidence linking unsafe abortions with increased maternal morbidity and mortality and most abortion-related maternal deaths are due to unsafe and illegal abortions. Although the overall abortion rate has declined, the proportion of unsafe abortions is increasing, especially in developing regions. Unsafe abortions are most common in countries with restrictive abortion laws. This suggests that improving abortion law reform could reduce maternal mortality, however, we do not have a rigorous evidence-base on which to support this premise.
  • Abortion legislation is another issue of primary concern in promoting reproductive health. Globally there are around 33 million legal abortions performed annually. It is estimated that illegal abortions contribute further to make a total of between 40 and 60 million. This means that for every known pregnancy there are between 24 and 32 induced abortions. It was estimated that in 2000 unsafe abortion accounted for a death toll of 68,000. Based on the 2000 figures it is estimated that 19 million unsafe abortions take place every year and that 1 in 270 such abortions result in maternal death.
  • Access to safe abortion services is an urgent need in the developing world as well, particularly in countries throughout Asia, Africa, and Latin America, where an estimated 68,000 deaths occur each year due to unsafe abortion procedures. Many more women (20 to 50% of those undergoing unsafe abortion) suffer from life-threatening complications. All too often those who survive are permanently scarred by these procedures that take place in hazardous and unsanitary conditions.
  • Unsafe abortions cause 50,000 to 100,000 deaths each year. In some countries complications of unsafe abortion cause the majority of maternal deaths, and in a few they are the leading cause of death for women of reproductive age. The World Health Organization estimates that as many as 20 million abortions each year are unsafe and that 10% to 50% of women who undergo unsafe abortion need medical care for complications. Also, many women need care after spontaneous abortion (miscarriage). In one country, for example, at 86 hospitals an estimated 28,000 women seek care for complications of unsafe or spontaneous abortion each month.
    The five main causes of maternal mortality are hemorrhage, obstructed labor, infection, pregnancy-induced hypertension, and complications of unsafe abortion. Many countries are undertaking programs to reduce deaths from the other four causes, but few provide adequate emergency medical care that would reduce maternal deaths from abortion complications. Even fewer provide family planning services and counseling to women treated for abortion complications.
  • Various methods of unsafe abortion have been reported. In the pre-penicillin era, instrumentation or introductions of fluid into the uterus caused fatalities. These methods still prevail, with women attempting instrumentation into the uterus per vagina and rarely, per abdomen. There are also a number of reported cases where quinine, misoprostol, over-the-counter medicines, livestock droppings, detergent and herbal medicines have been used as abortifacients. Unsafe abortion can lead to morbidity and mortality. Complications range from minor infections to death; the more common being bleeding, infection, uterine perforation and peritonitis.
  • A lack of awareness of the associated complications and psychosocial state may be reasons why women choose unsafe methods of abortion. It is a difficult task to identify which women fall into such categories, however an effort should be made to avoid the implications of unsafe abortion at the primary health care setting where women approach for contraception and/or counselling on abortion. Therefore, the importance lies in educating and making women aware not only of the safe legal methods of termination of pregnancy, but also of the complications that could follow unsafe procedures.
  • Benefits and potential impact Has the potential to prevent nearly all deaths (70,000) and disabilities (5 million) from unsafe abortion annually.
    *Saves an estimated.
    US$680 million in health-system costs for treating serious complications due to unsafe abortion.
    US$6 billion to treat post abortion infertility from unsafe abortion.
    US$930 million to society and individuals in lost income due to death or disability resulting from unsafe abortion.
    * Allows women and families to address consequences of contraceptive method failure.
  • ”All Governments and relevant intergovernmental and non-governmental organizations are urged to strengthen their commitment to women’s health, to deal with the health impact of unsafe abortion as a major public health concern and to reduce the recourse to abortion through expanded and improved family planning services.”
    • September, 1994 U.N. International Conference on Population and Development (ICPD) in Cairo

"Making abortions safe: a matter of good public health policy and practice" (2000)Edit

Berer M (2000). "Making abortions safe: a matter of good public health policy and practice". Bulletin of the World Health Organization. 78 (5): 580–92. PMC 2560758. PMID 10859852.

  • Globally, abortion mortality accounts for at least 13% of all maternal mortality. Unsafe abortion procedures, untrained abortion providers, restrictive abortion laws and high mortality and morbidity from abortion tend to occur together. Preventing mortality and morbidity from abortion in countries where these remain high is a matter of good public health policy and medical practice, and constitutes an important part of safe motherhood initiatives. This article examines the changes in policy and health service provision required to make abortions safe. It is based on a wide-ranging review of published and unpublished sources. In order to be effective, public health measures must take into account the reasons why women have abortions, the kind of abortion services required and at what stages of pregnancy, the types of abortion service providers needed, and training, cost and counselling issues. The transition from unsafe to safe abortions demands the following: changes at national policy level; abortion training for service providers and the provision of services at the appropriate primary level health service delivery points; and ensuring that women access these services instead of those of untrained providers. Public awareness that abortion services are available is a crucial element of this transition, particularly among adolescent and single women, who tend to have less access to reproductive health services generally.
    • p.580
  • Who estimates that about 25% of all pregnancies worldwide end in an induced abortion, approximately 50 million each year. Of these abortions, 20 million are being performed under dangerous conditions, either by untrained providers or using unsafe procedures, or both. Deaths as a result of unsafe abortions in developing countries are estimated at 80 000 annually, i.e. 400 deaths per 1000 000 abortions. This figure hides substantial regional variation, however, with unsafe abortions in Africa being at least 700 times more likely to lead to death than safe abortions in developed countries. Although over the past 10 years there have been improvements in the safety of the abortion procedures used and access to treatment for complications for some women in developing countries, the number of women requiring treatment for serious complications of unsafe abortion remains very high and women never receive care at all.
    Unsafe abortion procedures, untrained abortion providers, restrictive abortion laws and high mortality and morbidity from abortion tend to occur in one and the same countries.
    • p.580
  • Making abortion legal is an essential prerequisite to making it safe. In this respect, changing the law does matter and assertions to the contrary are ill conceived and unsupported in practice. Although, in many countries, trends towards safer abortion have often occurred prior to or in the absence of changes in the law, legal changes need to take place if safety is to be sustained for all women.
    Safety is not only a question of safe medical procedures being used by individual providers. It is also about removing the risk of exposure and the fear of imprisonment and other punitive measures for both women and providers, even where illegal abortion is tolerated. Health professionals providing safe but clandestine abortion in urban Latin America have described a lack of medical support, the need for secrecy, as well as threats of violence, extortion and prosecution.
    • p.582
  • Both the content of the law and the policy that defines how the law will be implemented matter. It is often in the “details” that service delivery is facilitated or blocked. Zambia and India are often erroneously cited as examples of why changing the law does not matter, as both are classified as countries where abortion is “legal” but where abortion mortality remains high. However, the term “legal” does not necessarily mean that the law is appropriate for the circumstances in which it must be implemented. Abortion mortality remains high in Zambia and India because of obstacles to putting the law into practice, including provider unwillingness, lack of training for providers, failure to authorize providers and facilities, and a lack of resources for and commitment to delivering good services at the primary care level. In Zambia, the law requires several doctors’ signatures for an abortion when in most places there are few or no doctors and lack of resources is an important issue.
    • p.582
  • Most developed countries still require that gynaecologists carry out abortions, yet this is not necessary, particularly not for abortions performed under 14 weeks of pregnancy, given that the skills needed have been greatly simplified and the rate of complications is so low. With appropriate training, nurse-midwives or those with comparable training would be the most appropriate abortion providers.
    Training of trainers, provision of equipment and training in vacuum aspiration techniques, and in how to provide medical abortions are needed. In many countries, one of the consequences of the longstanding illegality of abortion is that many providers are still using dilation and curettage and other outdated methods, which have not been in use in developed countries for many years since they have a higher rate of morbidity.
    • p.586
  • Along with safe methods and trained providers, programmes require locally accessible services in both rural and urban areas. In Zambia, gynaecologists were found to be a major obstacle to the setting up of safe abortion services.
    • p.586
  • Bringing abortion services out into the open is a precondition for ensuring quality of care, accessibility, availability and affordability, especially for the poorest women. This encourages health professionals to provide a defensible service. In Guyana, for example, although most clandestine abortion providers were medical professionals before the law was changed in 1995, septic abortion was the third highest cause (19%) of hospital admissions. After the law changed, this same group of providers organized themselves and voluntarily began to give prophylactic antibiotics. Admissions to the main public hospital for septic and incomplete abortions fell by 41% within 6 months of the decision.
    • pp.586-587
  • Public visibility in service provision means that women will have a more open choice of providers and can take action if their rights are violate or care is substandard; legalization also ensures that providers who attempt to sexually molest clients, anecdotally a not uncommon problem for women seeking clandestine abortions can be prosecuted. Sympathetic treatment on the part of service providers is important. Uncaring treatment and verbal abuse on the part of health care staff towards women seeking treatment for complications of clandestine abortion has been well documented in Latin America.
    • p.587
  • Abortion law reform is a necessary condition for making abortion safe, though it is not sufficient in itself. Women remain vulnerable where safe abortion is not legally sanctioned because quality of care cannot be assured, abuses cannot be challenged and both women and providers remain at risk of prosecution, blackmail and social and professional stigma. The dedication of individuals to providing treatment for abortion complications or safe abortions in a context of clandestinity, as important as it is, cannot make up for the absence of a legal framework and national programmes. In the long run, abortion needs to be decriminalized in order for it to be made safe.
    • p.588

"Evidence supporting broader access to safe legal abortion" (1 October 2015)Edit

Faúndes, Anibal; Shah, Iqbal H. (1 October 2015). "Evidence supporting broader access to safe legal abortion". International Journal of Gynecology & Obstetrics. World Report on Women's Health 2015: The unfinished agenda of women's reproductive health. 131: S56–S59. doi:10.1016/j.ijgo.2015.03.018. ISSN 0020-7292. PMID 26433508.

  • Unsafe abortion continues to be a major cause of maternal death; it accounts for 14.5% of all maternal deaths globally and almost all of these deaths occur in countries with restrictive abortion laws. A strong body of accumulated evidence shows that the simple means to drastically reduce unsafe abortion-related maternal deaths and morbidity is to make abortion legal and institutional termination of pregnancy broadly accessible. Despite this evidence, abortion is denied even when the legal condition for abortion is met. The present article aims to contribute to a better understanding that one can be in favor of greater access to safe abortion services, while at the same time not be “in favor of abortion,” by reviewing the evidence that indicates that criminalization of abortion only increases mortality and morbidity without decreasing the incidence of induced abortion, and that decriminalization rapidly reduces abortion-related mortality and does not increase abortion rates.
  • A recent assessment of global maternal, newborn, and child health indicated that unsafe abortion continues to exert a heavy toll on women’s lives and well-being as it accounts for 14.5% of all maternal deaths globally. These deaths are entirely preventable if women have access to safe legal abortion, as has been shown by the accumulated evidence and abortion reforms in a number of countries, including Guyana, Nepal, and South Africa. Of course, the primary prevention for unintended pregnancy is through consistent use of effective contraception. However, no contraceptive method is 100% effective, resulting in accidental pregnancies that the WHO has estimated to total 33.5 million each year. In addition, many women—mostly young—suffer sexual violence and rape and some become pregnant with an unwanted pregnancy. Thus, the simple means to practically eliminate all unsafe abortion-related complications and maternal deaths is to make abortion legal and institutional termination of pregnancy broadly available and accessible.
  • Declaring that one is in favor of greater access to safe abortion is not an easy decision for any individual or institution in the current environment of abortion stigma, harassment, and political backlash. It is only after careful evaluation of the evidence and the professional and ethical obligation to protect women’s health and lives that an organization such as FIGO can publicly declare to be in favor of women’s access to safe abortion. Hence, it is important to make clear the basis for such a courageous position.
    The first basic reason to favor broad access to safe abortion is that most women faced with an unintended/unwanted pregnancy resort to abortion, irrespective of the law. Where access to abortion is restricted, women will have no option but to risk their lives and health by resorting to an unskilled clandestine provider performing abortion under unhygienic conditions. Unsafe abortions cause suffering and death, as shown by numerous studies worldwide.
  • While the unsafe abortion rate is higher in Latin America than in Africa, the risk of death as a result of unsafe abortion is about 15 times higher for a woman living in Africa than for a woman living in Latin America. It is a rare exception for an abortion-related death to occur in a private hospital providing services to economically privileged women. Almost all deaths occur in public hospitals where poor women receive care or in their own homes, or wherever an abortion practitioner provides a clandestine and unsafe abortion service. Thus, the poorest women in the poorest countries are the main victims of criminalization of abortion and lack of access to safe abortion care.

"Unsafe abortion: The preventable pandemic" (2006)Edit

Grimes, DA; Benson, J; Singh, S; Romero, M; Ganatra, B; Okonofua, FE; Shah, IH (2006). "Unsafe abortion: The preventable pandemic" (PDF). The Lancet. 368 (9550): 1908–19. doi:10.1016/S0140-6736(06)69481-6. PMID 17126724. S2CID 6188636. Archived (PDF) from the original on 29 June 2011.

  • Ending the silent pandemic of unsafe abortion is an urgent public-health and human-rights imperative. As with other more visible global-health issues, this scourge threatens women throughout the developing world. Every year, about 19–20 million abortions are done by individuals without the requisite skills, or in environments below minimum medical standards, or both. Nearly all unsafe abortions (97%) are in developing countries. An estimated 68 000 women die as a result, and millions more have complications, many permanent. Important causes of death include haemorrhage, infection, and poisoning. Legalislation of abortion on request is a necessary but insufficient step toward improving women’s health; in some countries, such as India, where abortion has been legal for decades, access to competent care remains restricted because of other barriers. Access to safe abortion improves women’s health, and vice versa, as documented in Romania during the regime of President Nicolae Ceausescu. The availability of modern contraception can reduce but never eliminate the need for abortion. Direct costs of treating abortion complications burden impoverished health care systems, and indirect costs also drain struggling economies. The development of manual vacuum aspiration to empty the uterus, and the use of misoprostol, an oxytocic agent, have improved the care of women. Access to safe, legal abortion is a fundamental right of women, irrespective of where they live. The underlying causes of morbidity and mortality from unsafe abortion today are not blood loss and infection but, rather, apathy and disdain toward women.
    • p. 1908
  • Worldwide, an estimated 68 000 women die as a result of complications from unsafe induced abortions every year—about eight per hour. This prevalence translates into an estimated case-fatality rate of 367 deaths per 100 000 unsafe abortions, which is hundreds of times higher than that for safe, legal abortion in developed nations.
    • p. 1910
  • Nearly 5000 years ago, the Chinese Emperor Shen Nung described the use of mercury for inducing abortion. Although one publication lists over 100 traditional methods used for inducing abortion, unsafe methods today can be divided into several broad classes: oral and injectable medicines, vaginal preparations, intrauterine foreign bodies, and trauma to the abdomen (panel 2). In addition to detergents, solvents, and bleach, women in developing countries still rely on teas and decoctions made from local plant or animal products, including dung. Foreign bodies inserted into the uterus to disrupt the pregnancy often damage the uterus and internal organs, including bowel. In settings as diverse as the South Pacific and equatorial Africa, abortion by abdominal massage is still used by traditional practitioners. The vigorous pummelling of the woman’s lower abdomen is designed to disrupt the pregnancy but sometimes bursts the uterus and kills the woman instead.
    • p.1911
  • Increasing legal access to abortion is associated with improvement in sexual and reproductive health. Conversely, unsafe abortion and related mortality are both highest in countries with narrow grounds for legal abortion.33 More than 61% of the world’s population resides in countries where induced abortion is allowed without restriction or for a wide range of reasons such as protection of the woman’s life, preservation of her physical or mental health, and socioeconomic grounds.34 In 72 countries, most of which are in the developing world, 26% of the world’s population lives where abortion is prohibited altogether or allowed only to save the woman’s life.34 Most of these restrictive laws originated from European colonial laws from previous centuries, although the European nations discarded their restrictive abortion laws decades ago.
    • p.1911
  • The prevalence of unsafe abortions remains the highest in the 82 countries with the most restrictive legislations, up to 23 unsafe abortions per 1000 women aged 15–49 years. By contrast, the 52 countries that allow abortion on request have a median unsafe abortion rate as low as two per 1000 women of reproductive age.33 Although the case-fatality rate from unsafe abortions indicates the general level of health care and the availability of post-abortion services, the rate remains the highest in countries where abortion is legally restricted. In such countries, the median ratio for unsafe abortion mortality is 34 deaths per 100 000 livebirths; this ratio steadily decreases as legal grounds for abortion increase. The ratio falls to one or less per 100 000 livebirths in countries that allow abortion on request.33 Even in countries where improved access to health care and emergency obstetric services has greatly reduced overall maternal mortality, restrictive abortion laws translate into abortion deaths constituting a disproportionately high share of maternal deaths.
    Making abortion legal, safe, and accessible does not appreciably increase demand. Instead, the principal effect is shifting previously clandestine, unsafe procedures to legal and safe ones. Hence, governments need not worry that the costs of making abortion safe will overburden the health-care infrastructure. Countries that liberalised their abortion laws such as Barbados, Canada, South Africa, Tunisia, and Turkey did not have an increase in abortion. By comparison, the Netherlands, which has unrestricted access to free abortion and contraception, has one of the lowest abortion rates in the world.
    • p.1913
  • The indirect costs of unsafe abortion are substantial, yet more difficult to quantify. They include the loss of productivity from abortion-related morbidity and mortality on women and household members; the effect on children’s health and education if their mother dies; the diversion of scarce medical resources for treatment of abortion complications; and secondary infertility, stigma, and other sociopsychological consequences. For example, an estimated 220 000 children worldwide lose their mothers every year from abortion-related deaths. Such children receive less health care and social care than children who have two parents, and are more likely to die.
    • p.1914
  • Primary prevention includes reduction in the need for unsafe abortion through contraception, legalisation of abortion on request, the use of safer techniques, and improvement of provider skills. Access to safe, effective contraception can substantially reduce—but never eliminate–the need for abortion to regulate fertility. The effect of national contraceptive programmes on reducing the rate of abortion is well documented. In seven countries (Bulgaria, Kazakhstan, Kyrgyzstan, Switzerland, Tunisia, Turkey, and Uzbekistan), abortion rates fell as use of modern contraception rose. In another six countries (Cuba, Denmark, Netherlands, Republic of Korea, Singapore, and USA), abortion and contraception increased simultaneously; the uptake of effective contraception did not keep pace with couples’ increasing desires for smaller family sizes. In several of the six countries, abortion rates ultimately declined with continued contraceptive use and stabilisation of fertility rates at lower levels. Even with high rates of contraceptive use, however, unintended pregnancies will continue. No contraceptive method is 100% effective, and many couples in the developing world still encounter obstacles to contraception. Every year, 80 million women worldwide have an unintended pregnancy, and 60% of these are aborted. Thus, the need for safe abortion will continue. The developing world has seen a revolution in contraceptive use—from a mere 9% of couples using any method in 1960–6565 to 59% in 2003. Nevertheless, an estimated 27 million unintended pregnancies happen worldwide every year with the typical use of contraceptives. Six million would happen even with perfect (i.e., correct and consistent) use. An estimated 123 million women have an unmet need for family planning.
    • p.1914
  • The public health rationale to address unsafe abortion was first drawn to attention by the World Health Assembly four decades ago. In 1994, the Programme of Action of the International Conference on Population and Development stated, “In circumstances where abortion is not against the law, such abortion should be safe.” The Report of the Fourth World Conference on Women, held in Beijing in 1995, noted “unsafe abortions threaten the lives of a large number of women, representing a grave public health problem as it is primarily the poorest and youngest who take the highest risk”. At the Special Session of the UN General Assembly in June, 1999, governments agreed that “in circumstances where abortion is not against the law, health systems should train and equip health-service providers and should take other measures to ensure that such abortion is safe and accessible”. By investing in abortion safety and availability, governments throughout the world can save the lives of tens of thousands of women every year.
    • p.1917
  • Unsafe abortion endangers health in the developing world, and merits the same dispassionate, scientific approach to solutions as do other threats to public health. Although the remedies are available and inexpensive, governments in developing nations often do not have the political will to do what is right and necessary. The beneficiaries of access to safe, legal abortion on request include not only women but also their children, families, and society—for present and future generations. Women have always had abortions and will always continue to do so, irrespective of prevailing laws, religious proscriptions, or social norms. Although the ethical debate over abortion will continue, the public-health record is clear and incontrovertible: access to safe, legal abortion on request improves health. As noted by Mahmoud Fathalla, “Pregnancy-related deaths ... are often the ultimate tragic outcome of the cumulative denial of women’s human rights. Women are not dying because of untreatable diseases. They are dying because societies have yet to make the decision that their lives are worth saving.” Simply put, they die because they do not count.
    • p.1917

"Unsafe abortion: unnecessary maternal mortality" (2009)Edit

Haddad, LB; Nour, NM (2009). "Unsafe abortion: unnecessary maternal mortality". Reviews in Obstetrics & Gynecology. 2 (2): 122–26. PMC 2709326. PMID 19609407.

  • Every year, worldwide, about 42 million women with unintended pregnancies choose abortion, and nearly half of these procedures, 20 million, are unsafe. Some 68,000 women die of unsafe abortion annually, making it one of the leading causes of maternal mortality (13%). Of the women who survive unsafe abortion, 5 million will suffer long-term health complications. Unsafe abortion is thus a pressing issue. Both of the primary methods for preventing unsafe abortion—less restrictive abortion laws and greater contraceptive use—face social, religious, and political obstacles, particularly in developing nations, where most unsafe abortions (97%) occur. Even where these obstacles are overcome, women and health care providers need to be educated about contraception and the availability of legal and safe abortion, and women need better access to safe abortion and postabortion services. Otherwise, desperate women, facing the financial burdens and social stigma of unintended pregnancy and believing they have no other option, will continue to risk their lives by undergoing unsafe abortions.
  • According to the World Health Organization (WHO), every 8 minutes a woman in a developing nation will die of complications arising from an unsafe abortion. An unsafe abortion is defined as “a procedure for terminating an unintended pregnancy carried out either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both.”1 The fifth United Nations Millennium Development Goal recommends a 75% reduction in maternal mortality by 2015. WHO deems unsafe abortion one of the easiest preventable causes of maternal mortality and a staggering public health issue.
  • Obtaining accurate data for abortions is challenging, and especially so for unsafe abortion. Two-thirds of nations do not have the capacity to collect data, and data collection varies from country to country in both quantity and quality.2 Because unsafe abortion is often done clandestinely by untrained individuals or by the pregnant women themselves, much of it goes undocumented; figures are therefore estimates. Data suggest that even as the overall abortion rate has declined, the proportion of unsafe abortion is on the rise, especially in developing nations. From 1995 to 2003, the overall number of abortions declined, but the unsafe abortion rate was steady (from 15 to 14 abortions per 1000 women, respectively), constituting an increase from 44% to 48%.
  • Even safe abortion in developing nations carries risks that depend on the health facility, the skill of the provider, and the gestational age of the fetus. With unsafe abortion, the additional risks of maternal morbidity and mortality depend on what method of abortion is used, as well as on women’s readiness to seek postabortion care, the quality of the facility they reach, and the qualifications (and tolerance) of the health provider. Methods of unsafe abortion include drinking toxic fluids such as turpentine, bleach, or drinkable concoctions mixed with livestock manure. Other methods involve inflicting direct injury to the vagina or elsewhere—for example, inserting herbal preparations into the vagina or cervix; placing a foreign body such as a twig, coat hanger, or chicken bone into the uterus; or placing inappropriate medication into the vagina or rectum. Unskilled providers also improperly perform dilation and curettage in unhygienic settings, causing uterine perforations and infections. Methods of external injury are also used, such as jumping from the top of stairs or a roof, or inflicting blunt trauma to the abdomen.
  • The burden of unsafe abortion lies not only with the women and families, but also with the public health system. Every woman admitted for emergency postabortion care may require blood products, antibiotics, oxytocics, anesthesia, operating rooms, and surgical specialists. The financial and logistic impact of emergency care can overwhelm a health system and can prevent attention to be administered to other patients.

"Induced abortion: estimated rates and trends worldwide" (2007)Edit

Sedgh G, Henshaw S, Singh S, Ahman E, Shah IH (2007). "Induced abortion: estimated rates and trends worldwide". Lancet. 370 (9595): 1338–45. CiteSeerX 10.1.1.454.4197. doi:10.1016/S0140-6736(07)61575-X. PMID 17933648. S2CID 28458527.

  • Unsafe and safe abortions correspond in large part with illegal and legal abortions, respectively. The findings presented here indicate that unrestrictive abortion laws do not predict a high incidence of abortion, and by the same token, highly restrictive abortion laws are not associated with low abortion incidence. Indeed, both the highest and lowest abortion rates were seen in

regions where abortion is almost uniformly legal under a wide range of circumstances.
Results of previous studies have shown a strong correlation between abortion and contraception use such that, in settings with steady fertility rates over time, abortion incidence declines as contraceptive use increases. An analysis of trends in Eastern Europe and western and south-central Asia indicates that this pattern is evident in those regions.

    • p.1343
  • [S]ome abortions in restricted settings are done by trained providers, but most abortions in these

settings have high risks to a woman’s life and health. In Africa, where abortion is highly restricted by law in nearly all countries, there are 650 deaths for every 100 000 procedures, compared with fewer than 10 per 100 000 procedures in developed regions.18 Worldwide, an estimated 5 million women are hospitalised every year for treatment of complications related to unsafe abortion. Moreover, illegal procedures are harmful even when they do not lead to these consequences, because they require women to take actions in violation of the law and often without the knowledge or support of their partners or family.

    • p.1344
  • Worldwide, the rate of unsafe abortion declined slightly between 1995 and 2003, but the proportion of all abortions that were unsafe increased from 44% to 48% in the same interval. These findings reinforce the need to ensure that existing resources for reducing the rates of unsafe

abortions are used as fully as possible. WHO has issued technical and policy guidance to assist countries in making safe abortion accessible to the full extent permitted by the law, which include: using the safe methods now available for first-trimester abortions, in particular manual and electric vacuum aspiration and medical abortion; training providers on safe and aseptic abortion practice; training mid-level health professionals to do these procedures to the extent allowed by law; ensuring that the needed equipment and supplies are available for safe and appropriate procedures; and providing high quality post-abortion care that includes contraceptive counselling and services.

    • p.1344

"Unsafe abortion: global and regional incidence, trends, consequences, and challenges" (December 2009)Edit

Shah, I; Ahman, E (December 2009). "Unsafe abortion: global and regional incidence, trends, consequences, and challenges" (PDF). Journal of Obstetrics and Gynaecology Canada. 31 (12): 1149–58. doi:10.1016/s1701-2163(16)34376-6. PMID 20085681. Archived from the original (PDF) on 16 July 2011.

  • An estimated 70 000 women die each year because of complications of unsafe abortion; the recent killing of Dr George Tiller is a stark reminder that providers of abortion also suffer grave consequences. This trend persists against the backdrop of major advances in the medical profession, especially in terms of the availability of safe and effective technologies and skills for induced abortion. Unsafe abortion presents one of the most critical global public health and human rights challenges of the present times.
    Each day 192 women die because of complications arising from unsafe abortion; that is one woman every eight minutes, nearly all of them in developing countries. These women are likely to have had little or no money to procure safe services; many of them are young, perhaps in their teens, living in rural areas and having little social support to deal with their unplanned pregnancy. Some of them have been raped, and some have experienced an accidental pregnancy due to the failure of the contraceptive method they were using or the incorrect or inconsistent way they used it. Some of them lacked knowledge of methods to prevent unintended pregnancy or did not have the means to obtain them. Some may have found contraceptive services hard to reach, while others may have been turned away by judgemental or insensitive providers. A large percentage of them may have first attempted to self-induce the abortion and failing that, they may have turned to an unskilled, but relatively inexpensive and affordable provider.
    • p.1150
  • Among the 5 million women who are estimated to suffer temporary or permanent disability each year because of unsafe abortion, more than three million are likely to suffer from the effects of reproductive tract infections and 1.7 million are estimated to develop secondary infertility. Overall, some 24 million women are estimated to be currently suffering from secondary infertility due to an unsafe abortion.
    • p.1155
  • The public health impact of unsafe abortion has long been recognized. As early as 1967, the World Health Assembly identified unsafe abortion as a serious public health problem in many countries. Discussions that grew out of the1968 International Conference on Human Rights in Tehran culminated in the new concept of “reproductive rights,” which was subsequently highlighted at the 1994 International Conference on Population and Development (ICPD). ICPD established a number of goals and targets, including universal access to reproductive health services by 2015. On induced abortion, the ICPD consensus statement noted:
    All Governments and relevant intergovernmental and non-governmental organizations are urged to strengthen their commitment to women’s health, to deal with the health impact of unsafe abortion as a major public health concern and to reduce there course to abortion through expanded and improved family-planning services....In circumstances where abortion is not against the law, such abortion should be safe. In all cases, women should have access to quality services for management of complications arising from abortion. Post-abortion counselling, education and family-planning services should be offered promptly, which will also help to avoid repeat abortion.
    • p.1155
  • The Special Session of the United Nations General Assembly in June–July 1999 urged countries that “in circumstances where abortion is not against the law, health systems should train and equip health-service providers and should take other measures to ensure such abortion is safe and accessible.” The Reproductive Health Strategy of the WHO, approved in 2004, noted that “[a]s a preventable cause of maternal mortality and morbidity, unsafe abortion must be dealt with as part of the Millennium Development Goal on improving maternal health and other international development goals and targets.”
    • p.1156
  • Given the broad recognition of unsafe abortion as a serious public health problem, it should be easy to agree on strategies and policies for addressing it effectively. However, the discourse is diverse, ranging from views of abortion as a human right and a woman’s choice, to assertions that liberalizing abortion increases the incidence of abortion. Some-times it is suggested that abortion is a taboo topic in certain cultural, social, or religious contexts or that there could be a public backlash against liberalizing the restrictions. There-fore, inaction is put forth as the best course of action. Much of the discourse has continued to be devoid of scientific evidence and informed discussion.
    • p.1157-1158

"Unsafe abortion: the global public health challenge" (April 27, 2009)Edit

Iqbal H. Shah & Elisabeth Ahman, Chapter 2 “Unsafe abortion: the global public health challenge”, in Paul M, Lichtenberg ES, Borgatta L, Grimes DA, Stubblefield PG, Creinin MD (eds.). “Management of unintended and abnormal pregnancy: comprehensive abortion care”. (April 27, 2009) Oxford: Wiley-Blackwell. ISBN 978-1-4051-7696-5.

  • The World Health Organization (WHO) defines “unsafe abortion” as a procedure for terminating an unintended pregnancy either by individuals without the necessary skills or in an environment that does not conform to the minimum medical standards, or both. With the advent and expanding use of early medical abortion, this definition may need to be modified to incorporate standards appropriate to these less technical methods of pregnancy termination.
    • p.18
  • More than 60% of the world’s population lives in countries where induced abortion is allowed for a wide range of reasons. Nevertheless, some of these countries have a high incidence of unsafe abortion. Current estimates indicate that only 38% of women aged 15 to 44 years live in countries where abortion is legally available and where no evidence of unsafe abortion exists. A number of countries allow abortion ob broad grounds, but unsafe abortions still occur outside the legal framework. Abortion has been, for example,, legal on request in India since 1972; however, many women are unaware that safe and legal abortion is available. Even those who know of its legality may not have access to safe abortion because of poor quality of services and/or economic and social constraints. Reports also suggest that unsafe abortions may be increasing in several of the newly independent states, formerly part of Russia, as a result of increased fees and fewer services for legal abortions.
    • p.18
  • In 2003, about 3% of all women of reproductive age worldwide had an induced abortion. Overall, the number of induced abortions declined from 46 million in 1995 to 42 million in 2003. Most of the decline occurred in developed countries (10.0 million to 6.6 million), with little change evident in developing countries (35.5 million to 35 million).
    Induced abortion rates are, however, surprisingly similar across regions. A woman’s likelihood of having an induced abortion is almost the same whether she lived in a developed country (26 per 1,000) or a developing country (29 per 1,000). The main difference is safety: abortion is primarily safe in the former and mostly unsafe in the latter. Latin America, which has some of the world’s most restrictive induced abortion laws, has the highest abortion rate (31 per 1,000), but other regions have similar rates: Africa and Asia (29), Europe (28) and North America (21), and Oceania (17). Induced abortion rates vary by subregion, however. Eastern Africa and South East Asia who a rate of 39 per 1,000 women, while other subregions in Africa and Asia exhibit rates between 22 and 28 per 1,000. The Caribbean and South America subregions have high rates of 35 and 33 per 1,000. However, the highest abortion rate remains in Eastern Europe (44 per 1,000). In Europe, most induced abortions are safe and legal and the abortion incidence has been low for decades. The abortion rate has fallen substantially in recent years in eastern Europe, as contraceptives have become increasingly available. Nevertheless, women continue to rely on induced abortion to regulate fertility to a greater extent in this region than elsewhere.
    • p.19
  • The distinction among regions becomes more marked when one compares the incidence and proportion of safe and unsafe abortions. In 2003, 48% of all abortions worldwide were unsafe, and more than 97% of these unsafe abortions occurred in developing countries. In Africa and Latin America abortions are almost exclusively unsafe; so are almost 40% of abortions in Asia. Unsafe abortion is rare in Europe. Legal restrictions on abortions have little effect on women’s propensity to terminate an unintended pregnancy. Restrictions do however, lead to clandestine abortions, which, in turn, injure and kill many women.
    • p.20
  • Since 1990, WHO has been collecting data and estimating the incidence of unsafe abortion. However, estimating the magnitude of unsafe abortion is complex for several reasons. Induced abortion is generally stigmatized and frequently censured by religious teaching or ideologies, which makes women reluctant to admit to having had an induced abortion. Surveys show that underreporting occurs even where abortion is legal. This problem is exacerbated in settings where induced abortion is restricted and largely inaccessible, or legal but difficult to obtain. Little information is available on abortion practice in these circumstances, and abortions tend to be unreported or vastly underreported. Moreover, clandestine induced abortions may be misreported as spontaneous abortion (miscarriage). The language used to describe induced abortion reflects this ambivalence: terms include “induced miscarriage” (fausse couche provoquee), “menstrual regulation,” and “regulation of a delayed or suspended menstruation.” In spite of these challenges, estimates of the frequency of unsafe abortion can be made mainly by using hospital data on abortion complications or abortion data from surveys and validated against the legal context of induced abortion, contraceptive prevalence, and total fertility rate (the average number of children a woman is likely to by the end of her reproductive years). Globally, WHO estimates that some 19 to 20 million unsafe abortions occurred each year between 1993 and 2003. This figure has remained relatively constant despite an increase in contraceptive prevalence during the same period. Although the transition to low fertility with smaller families has become a norm in most countries, family planning has not been able to entirely meet the need of couples to regulate fertility.
    • p.21
  • Globally, an estimated 1 in 10 pregnancies ended in an unsafe abortion in 2003, giving a ratio of 1 unsafe abortion to about 7 live births. The unsafe abortion rates or ratios for each region are estimated by dividing the number of unsafe abortions in that region by the regional number of all women aged 15 to 44 years or by the regional number of live births respectively, in the same reference year.
    • p.21
  • Absolute numbers of unsafe abortions cannot be compared meaningfully across regions and subregions or over time because of differing size of populations at risk.
    • p.29
  • Unsafe abortion rates close to 30 per 1,000 women aged 15 to 44 years are seen in both Africa and Latin America and the Caribbean; however, because of the higher numbers of births, the unsafe abortion ratio for Africa is only hal f that for Latin America. According to recent estimates, the number of unsafe abortions in South America may have reached a peak and begun to decline. If Cuba, where abortion is legally available upon request, is excluded from the calculation, the rate for the Caribbean falls between that for Central America (25 per 1,000) and South America (33 per 1,0000). The range of estimates for Africa is wide: eastern Africa has the highest rate of any subregion, at 39 per 1,0000, whereas South Africa has among the lowest, at 18 per 1,000 (not counting legal abortions of 5 per 1,000 women). The 1996 law liberalizing abortion in South Africa has clearly reduced the number of unsafe abortions in the subregion. Half of all unsafe abortions take place in Asia; however, rates and ratios are generally lower. Only in South-East Asia are rates and ratios similar to those of Africa and Latin America. South-Central Asia has the highest number of unsafe abortions of any subregion, owing to the sheer size of its population.
    • p.29
  • The ratio of unsafe abortion generally ranges from 10 to 20 unsafe abortions per 100 births. However, when declining fertility results in fewer and fewer births without an accompanying major shift from unsafe abortion to modern contraceptive uptakes, ratios become high. Also, where the motivation is stronger to end an unwatned or unintended pregnancy through abortion rather than unwanted birth, the ratio would be higher. Such is the case in South America (38 per 100), Central America (26 per 100), the Caribbean (26 per 100) for all countries vs. 19 per 100 for countries at risk) and South-East Asia (31 per 100 for all countries vs. 27 per 100 for countries at risk).
    • p.30
  • The interpretation of trends in unsafe abortion ratios is not straightforward because it is a composite index of the degree of motivation to terminate an unwanted pregnancy by induced abortion as well as the trends in unsafe abortion relative to live births. With the increasing motivation to regulate fertility, the unsafe abortion ratio increases.
    Notwithstanding the complex relationship between trends in fertility and trends in unsafe abortion ratios, two main patterns emerge. The first is represented by South America, and also includes Central America, the Caribbean, and South Africa, where fertility has decline to around 2.5 children per woman. South Africa nevertheless is distinct with legal, safe abortion increasingly replacing unsafe abortion. However, the case of South America is striking: the unsafe abortion ratio is still very high in spite of a rise in the prevalence of modern contraceptives from 50 to 65, with more than half o the modern method use attributable to sterilization to terminate childbearing. Nonetheless, an unmet need for spacing births appears to be met through unsafe abortion. The decline in regional numbers of births is because of the increasing tendency to regulate fertility by either contraceptive use or unsafe abortion. The speed of decline in fertility has outstripped the decline in unsafe abortion, thus accounting for relatively higher ratios.
    South-East Asia and South-Central Asia (and to some extent western Asia and Oceania) represent the other pattern of moderately high fertility of around three children per woman and less than 50% modern contraceptive method use. A moderate decline in the unsafe abortion rate is noticed with little change in the ratio relative to live births. The trend in western Asia is less clear, because available data are generally limited.
  • Contraceptive methods remain inaccessible or limited in choice for married women in some countries. However, access to contraception is worse for unmarried women, particularly adolescents. The age patterns of unsafe abortion reveal these most vulnerable groups. A recent review found that two-thirds of unsafe abortions occur among women aged 15-30 years. More importantly from a public health perspective, 2.5 million, or almost 14%, of all unsafe abortions in developing countries occur among women younger than 20 years of age.
  • Induced abortion is linked to the level and pattern of contraceptive use, unmet need for family planning, and, consequently, to the level of unplanned pregnancy. Nearly 40% of pregnancies (or about 80 million) worldwide are unplanned, the result of non-use of contraceptives, ineffective contraceptive use, method failure, or lack of pregnancy planning. Indeed, one in four of the world’s 133 million births is reported to be “unwanted” or mistimed.
    Unintended pregnancy and induced abortion can be reduced by expanding and improving family planning services and choices and by reaching out to communities and underserved population groups, including sexually active teenagers and unmarried women. Furthermore, any abortion, whether initiated within or outside the official health system, should be accompanied by appropriate family planning services.
    Even when people are motivated to regulate their fertility, unplanned pregnancies will occur if effective contraception is largely inaccessible or not consistently or correctly used. Many married women in developing countries do not have access to the contraceptive methods of their choice. The situation is even more difficult for unmarried women, particularly adolescents, who rarely have access to information and counseling on sexual and reproductive health and are frequently excluded from contraceptive services. An estimated 123 million women have an unmet need for family planning; that is, they want to limit or space childbearing but are not using any method of contraception.
  • Each year more than 5 million women having an unsafe abortion (about one in four) experience complications, placing heavy demands on scarce medical resources. Mortality because of unsafe abortion is estimated from the total maternal mortality level. The estimated number of maternal deaths as a result of unsafe abortion ranges between 65,000 and 70,000 deaths per year. This corresponds to one woman dying because of a botched abortion approximately every 8 minutes. The most recent estimate (for 2003) shows that nearly all deaths attributable to unsafe abortion occur in developing countries. In eastern, western, and middle Africa, where maternal mortality is high, the unsafe abortion-related mortality ratio is higher than anywhere else, double that of Asia and more than five times that of Latin America. Morbidity is an even more frequent consequence of unsafe abortion; the disease burden for Africa is exceptionally high, threatening women’s lives and health and straining scarce resourced.
  • The high risk of death from unsafe abortion in Africa reflects the procedures used and the poor availability, accessibility, and quality of services for management of complications. In middle, western, and eastern Africa, dangerous abortion methods, failing infrastructure, and poor public health facilities result in estimated case-fatality rates of around 800 per 100,000 procedures. IN contrast, South and Central America have case-fatality rates lower than 100 per 100,000 as a result of better infrastructures for health services and wider use of misoprostol. For Southern and Northern Africa and South-East Asia, the rates appear low but are still almost 200 times higher than that associated with a legal and safe abortion in the USA.
  • Although unsafe abortion accounts for 13% of maternal deaths, it causes one-fifth of the total burden of the consequence of pregnancy and childbirth complications. The DALY of 100 per 1000 unsafe abortions in Latin America and the Caribbean is estimated to be the lowest among developing regions. The DALYs in Africa, Asia, and Oceania are six times, four times, and three times higher, respectively. These disparities reflect the risks because of abortion methods as well as access to health services in case of complications.
    The most common causes for women to seek hospital care following an unsafe abortion are sepsis, hemorrhage, and trauma. However, for every woman who seeks medical care, many more have chronic pelvic or back pain and other complications.
  • Induced abortion is arguably the most important human rights and equity issue of our time. Induced abortion exists in all parts of the world. Legal restrictions, mostly in developing countries, make abortion clandestine. The persistence of unsafe abortion continues to exert a heavy toll on women’s lives, especially in poor regions of the world and among the most disadvantaged.

"Abortion and maternal mortality in the developing world" (2006)Edit

Okonofua, F. (2006). "Abortion and maternal mortality in the developing world" (PDF). Journal of Obstetrics and Gynaecology Canada. 28 (11): 974–79. doi:10.1016/S1701-2163(16)32307-6. PMID 17169222. Archived from the original (PDF) on 11 January 2012.

  • Unsafe abortion is an important public health problem, accounting for 13% of maternal mortality in developing countries. Of an estimated annual 70 000 deaths from unsafe abortion worldwide, over 99% occur in the developing countries of sub-Saharan Africa, Central and Southeast Asia, and Latin America and the Caribbean. Factors associated with increased maternal mortality from unsafe abortion in developing countries include inadequate delivery systems for contraception needed to prevent unwanted pregnancies, restrictive abortion laws, pervading negative cultural and religious attitudes towards induced abortion, and poor health infrastructures for the management of abortion complications. The application of a public health approach based on primary, secondary, and tertiary prevention can reduce morbidity and mortality associated with unsafe abortion in developing countries. Primary prevention includes the promotion of increased use of contraception by women (and by men) at risk for unwanted pregnancy; secondary prevention involves the liberalization of abortion laws and the development of programs to increase access to safe abortion care in developing countries. In contrast, tertiary prevention includes the integration and institutionalization of post-abortion care for incomplete abortion and the early and appropriate treatment of more severe complications of abortion. Efforts to address these problems will contribute both to reducing maternal mortality associated with induced abortion and to achieving the Millennium Development Goals in developing countries.
    • p.974
  • Induced and unsafe abortion is a critical public health problem and an important cause of maternal mortality in developing countries. Worldwide, of the 600 000 maternal deaths from pregnancy-related causes each year, an estimated 13% are attributable to complications of induced and unsafe abortion. Many of these deaths occur in developing countries where abortion laws are often restrictive and

access to safe abortion is largely denied to women with unwanted pregnancies. Abortion-related deaths are hundreds of times more common in Latin America, sub- Saharan Africa, and Southeast and south Central Asia than in more developed regions of the world, where women have better access to safe abortion practices and procedures. The World Health Organization (WHO) estimates that in developing countries, 67 500 women die from abortion complications each year; in developed countries, 300 die each year.

    • p.974
  • Abortion is a largely preventable source cause of maternal mortality. Technologies and skills to prevent unwanted pregnancies and unsafe abortion are generally available in both developed and some developing countries. A recent World Bank analysis indicates that 90% of abortion-related mortality could be reduced simply by providing safe abortion care. However, lack of political will and lack of resources to apply these technologies are responsible for the high rate of maternal mortality associated with induced abortion in developing countries. Abortion mortality almost exclusively affects women in developing countries, and it is the disadvantaged, poor, and rural women in these countries who are most affected.
    • p.975
  • Abortion is highly restricted in many parts of the developing world. Of the 107 countries around the world that either prohibit or strongly restrict access to legal abortion services, the only industrialized countries are Poland and the Republic of Ireland. The rest are developing and low-income countries in Africa, Southeast and Central Asia, and South America and the Caribbean. Abortion laws in developing countries were derived from laws of European colonizers; however, although these European countries (notably Britain, France, Portugal, and Spain) have modernized their laws, many of the colonized countries have continued to maintain the old laws despite years of independence. Contrary to their intended purpose, however, restrictive laws have not prevented abortion in these countries; instead the laws have criminalized women and driven the practice of abortion underground, making it unsafe for women.
    • p.976
  • In many developing countries, because of restrictive abortion laws, termination of

pregnancy is undertaken either by women themselves, using highly dangerous methods, or by “backstreet” abortionists lacking minimal training, skills, and experience. The consequence is a high rate of associated complications that result in mortality. Data indicate that more than 30% of women seeking termination of pregnancy in countries with restrictive abortion laws may experience moderate to severe complications.

    • p.976
  • In Zambia and Ghana, two countries in Africa with liberal abortion laws, the lack of strong service delivery systems that integrate abortion and post-abortion care is the major reason that women in those countries still suffer complications of unsafe abortion. Women, and many providers, in these countries are not even familiar with opportunities provided under the law to terminate unwanted pregnancies safely, and policymakers do not regularly provide and disseminate clear guidelines and procedures for abortion and post-abortion care. In Indonesia, the negative attitudes of providers often prevent women from seeking menstrual regulation approved by the Ministry of Health. These negative attitudes by health providers are also carried over to women who suffer complications of induced abortion and
    • pp.976-977
  • The continued low contraceptive prevalence rates in developing countries account for the high rate of unwanted pregnancies that lead to unsafe and induced abortion-related mortality. Data from the United Nations Population Fund (UNFPA) indicate that the prevalence of modern contraceptive use is currently around 55% for Asia, 49% for Latin America and the Caribbean, and only 15% for sub-Saharan Africa, with large unmet needs for contraception in many of these countries.
    • p.977
  • Pregnancies can now be terminated using eminently safe methods such as manual vacuum aspiration (MVA) and mifepristone and misoprostol regimens. Programs that

aim to reduce abortion mortality must teach the appropriate use of these methods to physicians and to mid-level providers such as nurses and midwives, as has been done in Ghana and South Africa, to decentralize the use of these methods for the effective secondary prevention of abortion mortality. Programs to integrate the teaching of these methods into medical, midwifery, and nursing curricula are also useful and should be pursued in developing countries.

    • p.977
  • The most common complication of unsafe abortion in developing countries is incomplete abortion. There is now incontrovertible evidence that MVA is more cost-effective and safer than traditional dilatation and curettage (D&C) in treating incomplete abortion in developing countries. MVA used as part of post-abortion care has found increasing acceptability among health workers, health administrators, and policymakers in developing countries. However, many countries are still grappling with several issues relating to its provision, including key aspects of clinical care, information, and counselling, the extent to which MVA use can be decentralized to mid-level providers, the cost of services, and the provision of post-abortion family

planning to women with incomplete abortion. The extent to which these related issues are resolved in each country will determine the extent to which post-abortion care can contribute to reducing abortion-related maternal mortality in developing countries in the coming years.

    • p.978
  • The application of a public health approach based on primary, secondary, and tertiary prevention can reduce morbidity and mortality associated with unsafe abortion in developing countries. Primary prevention includes the promotion of increased use of contraception by women at risk of unwanted pregnancy. Secondary prevention involves the liberalization of abortion laws and programs to increase women’s access to safe abortion care in developing countries. Tertiary prevention includes the integration and institutionalization of post-abortion care for incomplete

abortion and the early and appropriate treatment of more severe complications of abortion. Efforts to address these problems will contribute to reducing maternal mortality associated with induced abortion and to achieving the MDGs in developing countries

    • p.978

“Unsafe abortion : global and regional estimates of the incidence of unsafe abortion and associated mortality in 2003” (2007)Edit

Swett, C. (2007). “Unsafe abortion : global and regional estimates of the incidence of unsafe abortion and associated mortality in 2003” (5th ed.). World Health Organization. ISBN 978-92-4-159612-1. Archived from the original on 7 April 2018. Retrieved 24 March 2018.

  • Unsafe abortion continues to be a major public health problem in many countries. A woman dies every eighth minute somewhere in a developing country due to complications arising from unsafe abortion. She was likely to have had little or no money to procure safe services, was young – perhaps in her teens – living in rural areas and had to procure safe services, was young – perhaps in her teens – living in rural areas and had little social support to deal with her unplanned pregnancy. She might have been raped or little social support to deal with her unplanned pregnancy. She might have been raped or she might have experienced an accidental pregnancy due to the failure of the contraceptives she might have experienced an accidental pregnancy due to the failure of the contraceptive method she was using or the incorrect or inconsistent way she used it. She probably first attempted to self-induce the termination and after that failed, she turned to an unskilled, but relatively inexpensive, provider. This is a real life story of so many women in developing countries in spite of the major advancements in technologies and in public health.
    • Halfdan Mahler, Preface, 25 September 2007
  • This report gives estimates of the number of unsafe abortions and associated mortality for the year 2003. Nearly 20 million unsafe abortions took place that year, 98% of them in developing countries with restrictive abortion laws. These countries often also have low rates of use of modern reversible contraceptives and high levels of unmet need for family planning.
    • Abstract
  • Methods to terminate an unwanted or unintended pregnancy are known to have existed since ancient times. As far back as 5000 years ago, the Chinese Emperor Shen Nung described the use of mercury for inducing abortion.1 A recent publication lists over 100 traditional methods of inducing abortion, which can be broadly classified into four categories: (1) oral and injectable medicines; (2) vaginal preparations; (3) introduction of a foreign body into the uterus; and (4) trauma to the abdomen. Many of these methods pose serious threats to the woman’s life and well-being.
    Each year, throughout the world, approximately 210 million women become pregnant and some 130 million of them go on to deliver live-born infants. The remaining 80 million pregnancies end in stillbirth, or spontaneous or induced abortion. Approximately 42 million pregnancies are voluntarily terminated each year – 22 million within the national legal system and 20 million outside it. In the latter case, the abortions are often performed by unskilled providers or in unhygienic conditions, or both.
    Only one in three legal (and mostly safe) abortions take place in developing countries (excluding China), while 98% of unsafe abortions occur there. Over five million or approximately 1 in 4women having an unsafe abortion is likely to face severe complications, which can cause death, and will seek hospital care, putting heavy demand on scarce resources. Unsafe abortion nonetheless remains a neglected health care problem in developing countries.
    • p.1
  • The World Health Organization (WHO) is concerned with the public health aspects of unsafe abortion. As early as 1967, the World Health Assembly passed Resolution WHA20.41, which stated that “abortions ... constitute a serious public health problem in many countries”, and requested the Director-General to “continue to develop the activities of the World Health Organization in the field of health aspects of human reproduction”. WHO defines unsafe abortion as a procedure for terminating an unintended pregnancy carried out either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both.
    The consensus statement of the 1994 International Conference on Population and Development (ICPD) noted that “All Governments and relevant intergovernmental and non-governmental organizations are urged to strengthen their commitment to women’s health, to deal with the health aspect of unsafe abortion as a major public health concern and to reduce the recourse to abortion through expanded and improved family-planning services.”
    The above was reiterated in 1999 at the five-year review of the implementation of the ICPD Programme of Action by the UN General Assembly in New York, USA. The Assembly further agreed that, “in circumstances where abortion is not against the law, health systems should train and equip health-service providers and should take other measures to ensure that such abortion is safe and accessible.”
    • p.1
  • The incidence of unsafe abortion is influenced by the legal provisions governing access to safe abortion, as well as the availability and quality of legal abortion services. Restrictive legislation is associated with a high incidence of unsafe abortion.
    • p.2
  • It has been estimated that almost 40% of pregnancies worldwide are unplanned – the result of non-use of contraception, ineffective contraceptive use or method failure. Unintended pregnancy, and induced abortion, can be prevented and reduced by expanding and improving family planning services and choices, reaching out to communities and underserved population groups, for example sexually active teenagers and unmarried women.
    • p.2
  • When people are motivated to regulate their fertility, but effective contraception is largely inaccessible or not consistently or correctly used, a large number of unplanned pregnancies occur. Many married women in developing countries do not have access to the contraceptive methods of their choice. The situation is even more difficult for unmarried women, particularly adolescents, who rarely have access to information and counselling on sexual and reproductive health, and are frequently excluded from contraceptive services. An estimated 123 million women have an unmet need for family planning. During rapid transition from high to low fertility, as has been witnessed in several countries, contraceptive services are often unable to meet the growing demand of couples for fertility regulation, resulting in an increased number of unplanned pregnancies, some of which are terminated by induced abortion. Also, where less effective family planning methods are commonly used, unplanned pregnancies and, consequently, abortions are likely to occur. Of course, no contraceptive method is 100% effective. It is estimated that each year 27 million unintended pregnancies occur as a result of method failure or ineffective use; of these, about 6 million occur even though the contraceptive method has been used correctly and consistently.
    • pp.2-3
  • Each year, an estimated 80 million women have an unplanned pregnancy. Some of these women will decide to continue the pregnancy, while others will consider having an abortion. A number of women who attempt to have an abortion will not be successful, and will carry the unwanted pregnancy to term. The number of women who attempt an unsafe abortion, risking their life and health, is 20–25% higher than the number who succeed. In addition, some women may make repeated attempts to terminate a pregnancy before succeeding, each time risking their health.
    • p.4
  • When induced abortion is performed by qualified persons using correct techniques and in sanitary conditions, it is a safe surgical procedure. In the USA, for example, the death rate from induced abortion is now 0.6 per 100 000 procedures, making it as safe as an injection of penicillin. In developing countries, however, the risk of death following unsafe abortion may be several hundred times higher. Spontaneous abortion is rarely fatal and seldom presents complications.
    The mortality and morbidity risks associated with unsafe induced abortion depend on the facilities and the skill of the abortion provider, the method used, the general health of the woman and the stage of her pregnancy. Unsafe abortion may be induced by the woman herself, by a non-medical person or by a health worker under unhygienic conditions. Abortion attempts may involve insertion of a solid object (root, twig or catheter) into the uterus; a dilatation and curettage procedure performed improperly by an unskilled provider; ingestion of harmful substances; exertion of external force; or misuse of modern pharmaceuticals. In many settings, traditional practitioners vigorously pummel the woman’s lower abdomen to disrupt the pregnancy; this can cause the uterus to burst, killing the woman.
    • p.5
  • One recent study estimated that every year in developing countries five million women are admitted to hospital as a result of unsafe abortion.5 The treatment of abortion complications in hospital consumes a significant share of resources, including hospital beds, blood supply, medications, and often operating theatres, anaesthesia and medical specialists. Thus, the consequences of unsafe abortion place great demands on the scarce clinical, material and financial resources of hospitals in many developing countries, undoubtedly compromising other maternity and emergency services. Major physiological, financial and emotional costs are also incurred by the women who undergo unsafe abortion.
    • p.5


  • A review of the combined impact of mortality and morbidity due to unsafe abortion estimated that, every year, there are 65 000 to 70 000 deaths and close to five million women with temporary or permanent disability due to unsafe abortion. Of these, more than 3 million suffer from the effects of reproductive tract infection (RTI), and almost 1.7 million will develop secondary infertility. Unsafe abortion accounts for 13% of maternal deaths, and 20 % of the total mortality and disability burden due to pregnancy and childbirth, in terms of disability-adjusted life years (DALYs).
    Altogether some 24 million women currently suffer secondary infertility caused by an unsafe abortion. In DALYs, the combined burden of mortality and morbidity per 1000 unsafe abortions is exceptionally high in sub-Saharan Africa, where it is 50 percentage points higher than in Asia and 6 times greater than in Latin America.
    • p.5
  • Where induced abortion is restricted and largely inaccessible, or legal but difficult to obtain, little information is available on abortion practice. In such circumstances, it is difficult to quantify and classify abortion. What information is available is inevitably not completely reliable, because of legal, ethical and moral considerations that hinder reporting. Occurrence tends to be under-reported in surveys, and unreported or under-reported in hospital records. Of course, there are no records on women who do not seek post-abortion care in hospitals. Only the “tip of the iceberg” is, therefore, visible in the number of deaths and the number of women who suffer severe trauma, or who have an infection or severe blood loss and seek medical care.
    Whether legal or illegal, induced abortion is generally stigmatized and frequently censured by religious teaching or ideologies. Women are often reluctant to admit to an induced abortion, especially when it is illegal, and under-reporting occurs even where abortion is legal. Whenabortions are clandestine, they may not be reported at all or may be reported as spontaneous abortion (miscarriage). The language used to describe induced abortion reflects this ambivalence: terms include “induced miscarriage” (fausse couche provoquée), “menstrual regulation”, and “regulation of a delayed or suspended menstruation”. For example, in one study 16.6% of women admitted to an abortion; however, only 4.4% said they had terminated a pregnancy, and 12.2% reported that they had “induced menstruation”. It is therefore not surprising that unsafe abortion is one of the most difficult indicators to measure.
    • pp.6-7
  • Induced abortions outside the legal framework are frequently performed by unqualified and unskilled providers, or are self-induced; such abortions often take place in unhygienic conditions, and involve the use of dangerous methods or incorrect administration of medications. Even when performed by a medical practitioner, an abortion that is carried out in secret, outside a recognized facility, generally carries an additional risk: medical back-up is not immediately available in an emergency, the woman may not receive appropriate post-abortion attention and care, and if complications occur, the woman may hesitate to seek care. The relative safety of unsafe abortion differs by country depending on the skills of the providers and the methods used, but is also linked to the de facto application of the law.
    • p.7
  • Unsafe abortion is negligible in eastern Asia and in some developing countries of other regions where abortion is legal and relatively accessible, in particular Cuba, Singapore, Tunisia, Turkey and Viet Nam. Rates and ratios that exclude these countries therefore provide a better reflection of the situation of unsafe abortion in the region or subregion as a whole.
    • p.8
  • Unsafe abortion rates close to 30 per 1000 women of reproductive age are seen in both Africa and Latin America; however, because of the higher relative number of births, the unsafe abortion ratio for Africa is only half that for Latin America. However, the range of estimates for Africa is wide: Eastern Africa has the highest incidence rate of any subregion, at 39 per 1000 women aged 15–44, while Southern Africa has among the lowest, at 18 per 1000 (not counting legal abortions of 5 per 1000 women). In Eastern, Western and Middle Africa, where maternal mortality is high, the unsafe-abortion-related mortality ratio is much higher than anywhere else – double that of Asia and more than 5 times that of Latin America. Morbidity is an even more frequent consequence of unsafe abortion, and it is thus not surprising that the total disease burden for Africa is exceptionally high, threatening women’s lives and health, and straining scarce resources.
    Middle, Western and Eastern Africa all have a contraceptive prevalence below 25%, with heavy reliance on traditional methods. In Southern and Northern Africa, contraceptive prevalence among married women is around 50%, and there is greater reliance on reversible modern methods (36% and 43%, respectively). This could help explain the moderate abortion rates of around 20 per 1000 women, as compared to 26 to 39 per 1000 in other parts of Africa.
    • p.15
  • The incidence of unsafe abortion for Latin America overall appears to have stabilized, and may have passed its peak. If Cuba is excluded from the calculation, the incidence rate for the Caribbean falls between those for Central America (25 per 1000) and South America (33 per 1000). The prevalence of modern contraceptives ranges from 57% to 66% in Latin America; however, 43–50% is accounted for by sterilization (Fig. 1). The moderate 29–38% prevalence of reversible method use could mean that unsafe abortion is being used to space births, to arrive at a total fertility rate of around 2.5 per woman.23 Improved access to a range of birth-spacing methods could reduce the number of unintended pregnancies and hence the need for abortion. Almost 2000 deaths from unsafe abortion occur, approximately 20 per 100 000 births; this is the lowest among the developing regions, and is attributable to the relatively well functioning health services in Latin America.
    • pp.15-16
  • South-central Asia has the highest number of unsafe abortions of any subregion, owing to the sheer size of its population; in 2003, there were 6.3 million unsafe abortions, or 18 per 1000 women of reproductive age, which poses a formidable challenge. Use of modern contraceptive methods among married women is modest (42%), and two-thirds of this use relates to sterilization; the high number of unsafe abortions is probably the result of a desire to space births. Nevertheless, among Asia’s subregions, South-eastern Asia has the highest incidence rate, at 27 per 1000 women aged 15–44 (excluding countries with no evidence of unsafe abortion); this rate is similar to those of the Caribbean and Central America. South-eastern Asia has a 51% prevalence of modern family planning methods, almost exclusively reversible methods (43%). It appears, though, that abortion is required to keep fertility low. The unsafe-abortion-related mortality for Asia is 2–3 times that for Latin America, but less than half that for Africa, reflecting the relative standards of health services and infrastructure.
    While it is acknowledged that there is a problem of unsafe abortion in Oceania, data are exceptionally scant and, as a consequence, estimates vary.
    • p.16
  • There has been a small reduction in the number of deaths in 2003 due to unsafe abortion compared with the estimate for 2000. This is in line with the assumption that maternal deaths in general may be slowly declining globally, probably as a result of improved maternity services and better cared.Overall, 66 500 maternal deaths were estimated to have been due to unsafe abortion in 2003. Nearly all of these deaths could have been prevented if the need for family planning had been met, and if abortion services had been legally available and affordable everywhere.
    • p.17
  • The estimated case-fatality rate (deaths per 100 000 unsafe abortion procedures) ranges from a high of 750 per 100 000 in sub-Saharan Africa to 10 per 100 000 in developed regions, with an average of 350 per 100 000 for developing regions. Table 3 also shows that the global case-fatality rate associated with unsafe abortion is some 550 times higher than the rate associated with legal induced abortions in the USA (0.6 per 100 000 procedures); in sub-Saharan Africa, the rate is well over 1000 times higher. Even in developed countries, the case-fatality rate for unsafe abortion is 20 times higher than that for legal induced abortion.
    • p.18
  • Major progress has been made in some areas of sexual and reproductive health, most notably in contraceptive use. However, unsafe abortions, though entirely preventable, continue to occur in almost all developing countries. The major public health implications include, but are not limited to, maternal morbidity and mortality. In addition, there are financial costs to women and to health services for treating complications.
    Governments need to assess the health impact of unsafe abortion, reduce the recourse to abortion by expanding and improving family planning services, and design abortion policies and interventions to improve women’s health and well-being. Preventing unintended pregnancies and unsafe abortion must continue to be a high priority for improving women’s sexual and reproductive health. Information and services for family planning and abortion care should be readily available, including to young people.
    In several countries, the legalization of abortion has not been followed by elimination of unsafe abortion. This may be because women are unaware that safe abortion services are available, or lack the resources, time or decision-making power to use the services, or because the services are inadequate to meet demand. Other factors inhibiting use of safe abortion where it is legal are lack of privacy and confidentiality, poor access, and discouraging attitudes of health care providers.
    • p.20

"Preventing unsafe abortion"Edit

"Preventing unsafe abortion". www.who.int. Retrieved 6 August 2019.

  • Abortions are safe when they are carried out with a method that is recommended by WHO and that is appropriate to the pregnancy duration, and when the person carrying out the abortion has the necessary skills. Such abortions can be done using tablets (medical abortion) or a simple outpatient procedure.
    An abortion is unsafe when it is carried out either by a person lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both. The people, skills, and medical standards considered safe in the provision of induced abortions are different for medical abortion (which is performed with drugs alone), and surgical abortion (which is performed with a manual or electric aspirator). Skills and medical standards required for safe abortion also vary depending upon the duration of the pregnancy and evolving scientific advances.
  • Based on data from 2010–2014, approximately 45% of all abortions worldwide were unsafe.
    Of all unsafe abortions, one third were performed under the least safe conditions, i.e. by untrained persons using dangerous and invasive methods.
    In Latin American and Africa, the majority (approximately 3 out of 4) of all abortions are unsafe.
    Estimates from 2012 indicate that in developing countries alone, an estimated 7 million women per year were treated in hospital facilities for complications of unsafe abortion.
  • In Africa, nearly half of all abortions happen in the least safe circumstances. Moreover, mortality from unsafe abortion disproportionately affects women in Africa. While the continent accounts for 29% of all unsafe abortions, it sees 62% of unsafe abortion-related deaths (2).
  • Health-care providers are obligated to provide life-saving medical care to any woman who suffers abortion-related complications, including treatment of complications from unsafe abortion, regardless of the legal grounds for abortion. However, in some cases, treatment of abortion complications is administered only on the condition that the woman provides information about the person(s) who performed the illegal abortion.
    The practice of extracting confessions from women seeking emergency medical care as a result of illegal abortion puts women's lives at risk. The legal requirement for doctors and other health-care personnel to report cases of women who have undergone abortion, delays care and increases the risks to women’s health and lives. UN human rights standards call on countries to provide immediate and unconditional treatment to anyone seeking emergency medical care.
  • In addition to the deaths and disabilities caused by unsafe abortion, there are major social and financial costs to women, families, communities, and health systems.
    Estimates from 2006 show that, in developing countries, the yearly cost for health systems include:
    *US$ 553 million for treating complications from unsafe abortion.
    *US$ 6 billion for treating post-abortion infertility.
    *A need for an additional US$ 373 million, if unmet needs for treating complications from unsafe abortion were to be met.
  • Unsafe abortion can also lead to short- and long-term financial costs for women and ultimately entire families and communities. Annual cost estimates for developing countries include:
    * US$ 200 million in out-of-pocket expenses of individuals and households, for the treatment of post-abortion complications, in sub-Saharan Africa alone.
    *US$ 922 million in loss of income as a result of long-term disability, due to infertility or pelvic inflammatory disease caused by unsafe abortion.

"Worldwide, an estimated 25 million unsafe abortions occur each year" (28 September 2017)Edit

"Worldwide, an estimated 25 million unsafe abortions occur each year". World Health Organization. 28 September 2017. Archived from the original on 29 September 2017. Retrieved 29 September 2017.

  • “Increased efforts are needed, especially in developing regions, to ensure access to contraception and safe abortion,” says Dr Bela Ganatra, lead author of the study and a scientist in the WHO Department of Reproductive Health and Research.
    “When women and girls cannot access effective contraception and safe abortion services, there are serious consequences for their own health and that of their families. This should not happen. But despite recent advances in technology and evidence, too many unsafe abortions still occur, and too many women continue to suffer and die.”
  • In countries where abortion is completely banned or permitted only to save the woman’s life or preserve her physical health, only 1 in 4 abortions were safe; whereas, in countries where abortion is legal on broader grounds, nearly 9 in 10 abortions were done safely. Restricting access to abortions does not reduce the number of abortions.
  • Among developing regions, the proportion of abortions that were safe in Eastern Asia (including China) was similar to developed regions. In South-Central Asia, however, less than 1 in 2 abortions were safe. Outside of Southern Africa, less than 1 in 4 abortions in Africa were safe. Of those unsafe abortions, the majority were characterized as “least safe.”
    In Latin America, only 1 in 4 abortions were safe, though the majority were categorized as “less safe,” as it is increasingly common for women in the region to obtain and self-administer medicines like misoprostol outside of formal health systems. This has meant that this region has seen fewer deaths and fewer severe complications from unsafe abortions. Nevertheless, this type of informal self-use of medication abortion that women have to resort to secretly does not meet WHO’s safe abortion standards.

"The Prevention and Management of Unsafe Abortion" (April 1992)Edit

"The Prevention and Management of Unsafe Abortion" (PDF). World Health Organization. April 1992. Archived (PDF) from the original on 30 May 2010. Retrieved 18 October 2017.

  • Complications resulting from unsafe abortion are an important cause of maternal mortality and morbidity. On a country-specific basis deaths related to complications of unsafe abortion range from under 10% to almost 60% of maternal deaths. These statistics are all the more compelling as the majority of these deaths are preventable with currently existing, but not universally available, drugs, technologies and management systems.
    The World Health Organization has assisted Member States for more than 25 years in addressing the public health concerns surrounding unsafe abortion, including awareness raising, identification of priority areas for intervention, prevention of unsafe abortion through family planning information and services, and training of health workers. At the Twentieth World Health Assembly in 1967, Resolution WHA 20.41, noted that “abortions…constitute a serious public health problem in many countries” and recommended that the Organization continue to work” in the field of health aspects of human reproduction”.
    • p.2
  • An integral objective of the WHO maternal Health and Safe Motherhood Programme is that family planning information and services should be available, accessible and affordable to all. Unfortunately this ideal has not been universally attained. In addition, contraceptive methods may fail. As a result large numbers of women throughout the world continue to rely on abortion as a means to end an unwanted pregnancy. Too often these women are risking their lives and health when the services they find are unsafe. This need to rely on unsafe abortion signals a failure of health systems to provide appropriate care of these women who are seeking a means to control their fertility. Within every health care context when there is a threat to health, a moral obligation exists to assess its impact and to ensure that humane and appropriate care is available and accessible. In the case of unsafe abortion, women’s lives and health are clearly threatened.
    The term “Unsafe Abortion” was used by the Technical Working Group to reflect concern for the safety of abortion services, which were the focus of its discussions rather than the legal issues surrounding abortion. Unsafe abortions are characterized by the lack or inadequacy of skills of the provider, hazardous techniques and unsanitary facilities. Unsafe abortion with its man resulting complications is responsible for the deaths and illness of hundreds of thousands of women each year. The legality or illegality of the services, however, may not be the defining factor of their safety. To prevent the deaths of women, the safety of abortion) whether elective induced abortion or the treatment of spontaneous or incomplete abortion) must be considered within both the legal and legally restricted contexts.
    An effective mechanism for teaching women more promptly with the care they require for complications of unsafe abortion is for appropriate and timely care to be available as close to women as possible.
    • p.3
  • The legal status of abortion by percentage of the world’s population affected imply the following statistics: 40% have access to abortion on request; 12% have access to abortion on grounds such as social, economic, or fetal indication; 23% have severely restricted access to abortion, usually only in cases such as saving the life of the mother; and for 25% abortion is prohibited through the health services on all grounds.
    Even in countries where abortion services are ostensibly available (roughly 50% of the world), services may not be accessible to women or women may be unaware that services are available. As a result a large proportion of the world’s women are without access to safe termination of pregnancy.
    In developed countries where safe abortion is readily available, abortion-related mortality is extremely low, at less than 1/100,000 procedures. In less optimal settings when women are only able to find unsafe abortion, mortality can be high.
    • p.4
  • Exact numbers of deaths from unsafe abortion are difficult to determine, in large part because it is almost impossible to estimate accurately a) abortion rates (i.e. number of abortion per women of reproductive age) and b) case fatality rates (i.e. the number of abortion deaths per total abortions).
    Data are usually derived from several sources, including hospital-based data, civil registration, and community-based data. Each of these sources can present a challenge to researchers for a variety of reasons, including lack of specificity of the cause of deaths, misclassification of the deaths, or reluctance to provide complete information.
    Given the data available, however, a range of estimates emerges, from a minimum of 50,000 to 150,000 abortion-related deaths annually. Some researchers believe that the often quoted 200,000 abortion-related deaths per year, which may have been true several years ago, is now in fact lower. This potential decline in annual abortion-reated deaths may be attributable to safer abortion care being more widely available. Whatever the number, the fact is that our health systems continue to fail women by letting preventable deaths occur.
    • pp.4-5
  • Care for complications of unsafe abortion must be extended throughout the health care system, particularly to the primary care level. Currently, many primary care centres do not provide any emergency stabilization or intervention for women with abortion complications prior to referral. Decentralization of services is essential, bringing with it more immediate life-saving care and preventing unnecessary deterioration in the woman’s condition when referral and transport is required.
    A critical step in the process of expanding access to care is the creation of a continuous chain of care, with providers at each level understanding their role in this chain. Providers, particularly at the primary and first referral levels of care, must receive training which clearly identifies their essential role in the prevention of maternal mortality and morbidity from abortion complications.
    Personnel at every level of care must recognize that complications from unsafe abortion are potentially life-threatening. Many women seeking care encounter health care providers who view this serious medical problem as a lower priority than other disorders. Training about the serious nature of abortion complications can help change these attitudes.
    • p.5
  • The management of unsafe abortion has been neglected as an area of research. Needs for additional research were considered in the context of clinical research needs and operations research needs. It was the consensus that there are few needs for clinical research in the treatment of abortion complications. However, there are many areas of need for operations research in implementing improved service delivery throughout the health care system.
    • p.8
  • Throughout much of the developing world women who have experienced complications of an unsafe abortion, whether or not they have been fortunate enough to reach a health facility for treatment, often receive no contraceptive information or services. These cases represent one group of women at high risk of unwanted pregnancy and repeat unsafe abortion. When the health system fails to provide appropriate family planning services it must be counted as a missed opportunity to assist women in the safe regulation of their fertility.
    A majority of both the clinical and service delivery studies which have been done with regard to post-abortion contraception have focused on issues unrelated to the specific circumstances of women who have been treated for complications of an unsafe abortion. Much of the clinical literature dates from the seventies and early eighties and, therefore, does not take into account newly developed or refined methods of contraception (e.g. Norplant, NET microspheres, new injectables, and multiphasic pills). In the area of the health system and its delivery of contraceptive information and services immediately following abortion, most of the existing literature is devoted to information and services following elective induced abortion.
    • p.13
  • While barrier methods were considered generally acceptable following an unsafe abortion, the universal concern about condoms as a male method over which women have little decision-making power was reiterated.
    In regard to IUDs, a specific concern is the possibility of increasing the risk or severity of infection. As many incomplete abortions are of uncertain safety and in many other cases infection is readily apparent, the Technical Working Group concluded that IUDs should not be recommended immediately following treatment of an unsafe abortion unless no other alternative exists. However, where the possibility of increasing the risk of severity of an infection appears to be minimal the IUD may be considered an acceptable method.
    The Technical Working Group considered sterilization immediately following treatment for complications of unsafe abortion and arrived at the following consensus. There is considerable potential for later regret if a woman chooses a permanent method at the time of abortion. The Group acknowledged that delaying a sterilization procedure could (a) present interference with fully informed consent due to stress and/or physical impairment related to the circumstances of the unsafe abortion, and (b) limit the potential for coercion by the health care provider. The other side of the coin, however, is that women wanting sterilization must wait for it. Interest was expressed in gaining a clearer understanding of the optimal timing for delay of sterilization following an unsafe abortion to minimize regret.
    All hormonal methods were considered acceptable for use following an unsafe abortion, and can be started following treatment, before the woman leaves the health facility.
    • p.14
  • The causes of unsafe abortion are rooted in a complex set of circumstances which are not easily solved. Nevertheless, practical strategies are available to us now to prevent much of the maternal mortality which results from unsafe abortion. Clinical treatment protocols, appropriate technologies, and management systems can be combined and tested to find the most effective solutions for any health system. Assessing women’s preferences in the design of family planning services, including information and services following treatment of abortion complications, will identify mechanisms that more effectively meet women’s needs. This step can correct failures in existing programmes, preventing many unwanted pregnancies.
    • p.17

“Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008” (2011)Edit

World Health Organisation (2011). “Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008”, (PDF). (6th ed.). World Health Organisation. ISBN 978-92-4-150111-8. Archived (PDF) from the original on 28 March 2014.

  • Deaths due to unsafe abortion remain close to 13% of all maternal deaths. Unsafe abortion-related deaths have, however, reduced to 47 000 in 2008 from 56 000 in 2003 and 69 000 in 1990; corresponding to the decline in the overall number of maternal deaths to 358 000 in 2008 from 546 000 in 1990. Although unsafe abortions are preventable, they continue to pose undue risks to women’s health and lives.
    • p.1
  • Each year, throughout the world, approximately 210 million women become pregnant and over 135 million of them deliver liveborn infants. The remaining 75 million pregnancies end in stillbirth, or spontaneous or induced abortion. It was estimated that in 2003 approximately 42 million pregnancies were voluntarily terminated: 22 million safely and 20 million unsafely. Unsafe abortions are frequently performed by providers lacking qualifications and skills to perform induced abortion, and some abortions are self-induced. Unsafe induced abortions do not meet officially prescribed circumstances and safeguards; they are aggravated by unhygienic conditions, dangerous interventions or incorrect administration of medication. Although unsafe abortions are preventable, they continue to pose undue risks to a woman’s health and may endanger her life.
    • p.2
  • Close to 20% of women aged 15–44 years live in countries where abortion is not legally permitted at all or restricted to saving the woman’s life, and 57% live in countries where induced abortion has fewer legal restrictions and women could request an abortion for a variety of reasons; nevertheless, unsafe abortions take place along the whole legal spectrum. Only 36% of women of reproductive age live in countries where there is no evidence of unsafe abortion, while 39% of women aged 15–44 years live in countries where abortion is available on request. These two groups of countries largely coincide, however, there are countries that do not allow abortion on request (for example, in the United Kingdom abortion is not permitted on the grounds of rape or incest, and in New Zealand not for socioeconomic reasons). India where abortion was legalized in 1971 presents the opposite situation: abortion is available on all grounds (although not on request), nevertheless, unsafe abortions take place. In a number of countries in eastern Europe and countries of the former Soviet Union that allow abortion on broad grounds or on request, some unsafe abortions occur outside the legal framework because of poor access to safe abortion services, for example in rural areas of the countries. In most countries where the law is less restrictive but services are unevenly distributed, for example in rural areas, unsafe abortions still take place. Other countries such as Cambodia, Guyana, Nepal, South Africa and, most recently, Ethiopia are in the process of implementing less-restrictive abortion laws with varying success and therefore show unsafe abortions in parallel with safe and legal services.
    • pp.4-5
  • Worldwide, unsafe abortions are estimated to be between 21 million and 22 million in 2008, almost 2 million more than the number estimated for 2003. There were approximately 210 million pregnancies in 2008; therefore around one in 10 pregnancies ends in an unsafe abortion worldwide. Nevertheless, the global rate at 14 per 1000 women aged 15–44 years remains unchanged since 2003; the increase in numbers of unsafe abortion therefore is mainly an effect of the increasing numbers of women of reproductive age in the world.
    • p.8
  • Reviewing 20 years of estimates for unsafe abortion incidence, rates and ratios show that unsafe abortion continues playing an important role in developing country regions. The numbers, rate and ratio show that women all over the world are likely to resort to an unsafe abortion when faced with an unwanted pregnancy and provisions for safe abortions are unavailable or inaccessible; and that in subregions with low fertility the ratio is relatively high.
    • p.26
  • Globally, the proportion of maternal deaths due to unsafe abortion has remained close to 13% over time. Contrary to the global percentage of maternal deaths due to unsafe abortion, the averages by subregions and regions are distinct and, furthermore, the percentage varies extensively between countries within each subregion, reflecting country specific circumstances of unsafe abortion incidence and access to care. Even as such variation is absorbed in averages, the aggregated regional and global numbers are more robust.
    • p.27
  • The global case–fatality rate (220 per 100 000) associated with unsafe abortion is some 350 times higher than the rate associated with legal induced abortions in the USA (0.6 per 100 000 procedures); in sub-Saharan Africa, the rate is more than 800 times higher. Even in developed countries, the case–fatality rate for unsafe abortion is 40 times higher than that for legal induced abortion.
    • p.30
  • Unsafe abortion and deaths due to complications of unsafe abortion continue to afflict the lives of many women, mostly in developing countries. Unsafe abortion is the cause of serious complications and disability for millions of women each year and is a prominent cause of maternal death. Despite efforts to achieve Millennium Development Goal 5 Target 5A – reduce by three quarters the maternal mortality ratio between 1990 and 2015 – the percentage of maternal deaths due to unsafe abortion remains unchanged at 13%. Numbers of unsafe abortions have risen with the increase in the number of women of reproductive age. This trend may continue unless women’s access to safe abortion and contraception – and support to empower women (including their freedom to decide whether and when to have a child) – are put in place and further strengthened.
    Unsafe abortions, though entirely preventable, continue to occur in almost all developing countries and in Eastern Europe. The evidence suggests that a reliance on abortion can be greatly reduced when:
    * women can plan pregnancies through effective contraception;
    * counselling and services meet the unmet need for family planning, and appropriate method mix of contraception is offered to all women, including both married and unmarried women; and
    * safe abortion services are available and accessible.
    • p.31

"Facts on Induced Abortion Worldwide" (January 2012)Edit

"Facts on Induced Abortion Worldwide" (PDF). World Health Organization. January 2012. Archived (PDF) from the original on 9 March 2021. Retrieved 9 May 2021.

  • Between 1995 and 2008, the rate of unsafe abortion worldwide remained essentially unchanged, at 14 abortions per 1,000 women aged 15-44.
    • p.2
  • In 2008, more than 97% of abortions in Africa were unsafe. Southern Africa is the subregion with the lowest proportion of unsafe abortions (58%). Close to 90% of women in the subregion live in South Africa, where abortion was liberalized in 1997.
    • p.2
  • In Latin America, 95% of abortions were unsafe, a proportion that did not change between 1995 and 2008. Nearly all safe abortions occurred in the Caribbean, primarily in Cuba and several other islands where the law is liberal and safe abortions are accessible.
    • p.2
  • In Asia, the proportion of abortion that are unsafe varies widely by subregion, from virtually none in eastern Asia to 65% in South Central Asia.
    • p.2
  • The estimated annual number of deaths from unsafe abortion declined from 56,000 in 2003 to 47,000 in 2008. Complications from unsafe abortion accounted for an estimated 13% of all maternal deaths worldwide in both years.
    • p.2
  • In the United States, legal induced abortion results in only 0.6 deaths per 100,000 procedures. Worldwide, unsafe abortion accounts for a death rate that is 350 times higher (220 per 100,000), and, in Sub-Saharan Africa, the rate is 800 times higher, at 460 per 100,000.
    • p.2
  • Unsafe abortion is a significant cause of ill-health among women in the developing world. Estimates for 2005 indicate that 8.5 million women annually experience complications from unsafe abortion that require medical attention, and three million do not receive the care they need.
    • p.3
  • Treating medical complications from unsafe abortion places a significant financial burden on public health care systems in the developing world. According to a 2009 study, the minimum annual estimated cost of providing postabortion care in the developing world is $431 million.
    • p.3

See alsoEdit

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